VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: March 22, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:13 am on 3/22/2023 and exited at 12:50 pm on 3/22/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/30/2023 and 3/1/2023 regarding allegations in the area(s) of personnel, and resident care and related services. Number of resident records reviewed: 2 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed video footage of an alleged abusive incident that took place on 3/1/2023. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based upon a review of records, the facility failed to ensure that all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of resident?s in accordance with that section. Evidence: 1. A written statement provided by Staff #2 on 3/2/2023, documented that on 3/1/2023, Staff #2 witnessed Staff #1 telling Resident #1 to ?shut up? and then witnessed Staff #1,?hit his (Resident #1?s) butt because of what he was saying.? 2. According to the written statement provided by Staff #2 on 3/2/2023, regarding the incident witnessed on 3/1/2023 in which Staff #1 struck Resident #1 on the butt, ? I know I should have reported this and I have to report this.? Staff #2 stated in her written statement of 3/2/2023, ?I should have reported but I didn?t report.?
Plan of Correction:	On March 8, 2023, all associates in Wellspring Village were required to watch the training video titled ?Recognizing, Reporting and Preventing Abuse.? The Executive Director, Health Services Director, and Wellspring Village Director, spoke to all associates prior to the video to explain why they were watching it and explained again that they are mandatory reporters of abuse, neglect, and exploitation. The facility terminated the two associates who observed the incident and explained (to the two associates) that it was because they did not report the abuse.
Standard #:	22VAC40-73-250-C
Description:	Based upon a review of records, the facility failed to ensure that personal and social data to be maintained on staff and included I the staff record are as follows: verification of current professional license. Evidence: 1. According to the record for Staff #2, the license for nurse aide for Staff #2 expired on 3/31/2022. 2. A search on the Virginia Department of Health Professions website conducted on 3/22/2023, confirmed that the nurse aide license for Staff #2 was currently expired.
Plan of Correction:	On 3/25/2023, the Executive Director reviewed the status of all licenses of health and wellness staff. Those who did not have updated licenses were taken off the schedule until their license was up to date.
Standard #:	22VAC40-73-640-A
Description:	Based upon a review of records, the facility failed to implement methods in the medication management plan to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. According to the written report provided by the facility, Staff #5, and Staff #6, on 1/30/2023, failed to follow the ?med tech protocol which says that incoming med tech/nurse and outgoing med tech/nurse must count the pills (controlled substances).? 2. A written statement provided by Staff #6, the incoming med tech on 1/30/2023, documents that Staff #6 arrived on the floor and stood in the door as the floor nurse (Staff #5) counted the pills with the outgoing med tech from the night shift.
Plan of Correction:	The wellness nurse and the med tech who failed to follow the plan were given performance counseling on 2/3/2023 for not counting medications before they turned over the keys to the medication cart which is a violation of our Medication Management Plan. The health services director (HSD) did a review of our Medication Management Plan (particularly page 6, item 15, Maintenance of Schedule II-V Medications) with the med techs and wellness nurse involved and also reviewed our entire Medication Management Plan with all med techs on 2/8/2023.